Jo Revillhttp://www.newstatesman.com/writers/jo_revill
enhttp://www.newstatesman.com/node/152638
<div class="field field-name-field-subheadline field-type-text-long field-label-hidden view-mode-fulltext"><div class="field-items"><div class="field-item even"><p>Observations on avian flu</p>
</div></div></div><div class="field field-name-body field-type-text-with-summary field-label-hidden view-mode-fulltext"><div class="field-items"><div class="field-item even" property="content:encoded"> <p>At least someone has been candid. Sir Liam Donaldson, the government's chief medical officer, has been saying for some time that the arrival of bird flu on our shores is a "biological inevitability".</p>
<p>The surprise is that anyone is surprised by the appearance of an infected duck in France, a major migratory pit stop for wildfowl. As birds start their seasonal migration back from Africa and the Mediterranean basin over the next few weeks, more cases are expected in the estuaries and marshes that fringe northern Europe.</p>
<p>For the past three years, the World Health Organisation (WHO) has been doing its best to warn of a global spread of the influenza A virus H5N1, as scientists charted its unsteady progress from south-east Asia across the Urals, down in Africa and across the European wetlands. Human casualties have so far been few, with 169 recorded cases of infections and 91 deaths. It is still possible that a pandemic can be avoided. But that possibility is receding as each reservoir of disease creates the opportunities ideal for a new virus to mutate while it adjusts to survive in a new species.</p>
<p>Now, as Continental governments advocate stringent measures, British ministers are facing serious questions over whether they've done enough. Tony Blair could and should have given a single cabinet minister overall charge of the response, as urged by the WHO. Instead, the various departments are moving along different tracks. Donaldson and the Department of Health organised emergency planning for the health service fairly quickly, badgering ministers to order millions of doses of the antiviral drugs.</p>
<p>But Britain's farmers, who still wield huge influence over the Department for Environment, Food and Rural Affairs (Defra), did not want to know about a disease rampant in faraway countries which could damage their poultry industry. After foot-and-mouth, many beef farmers switched to poultry as a safer bet, and the prospect of taking extra "bio-security" measures against their free-range market filled them with horror. This is why every European country, apart from the UK and Spain, has sensibly ordered poultry indoors or confined their movement in some way. The government's belief that hens could be moved indoors once the disease arrives in Britain would not solve the problem.</p>
<p>At least as worrying is the reluctance of most of Whitehall to discuss how basic services will be maintained in the event of a pandemic. It is estimated that such pandemics last roughly 16 weeks, and the assessment of some business organisations is that about 50 per cent of the workforce would stay at home at any one point during that period, due to a mixture of infections, school closures and fear. Among the gravest challenges would be to ensure that energy, food supplies and transportation still functioned.</p>
<p>However, Defra has been characteristically tight-lipped about food security. Late last year, the British Retail Consortium admitted that it had had to demand a meeting with the department in order to discuss the issue of how food would reach the supermarkets during a crisis. One might have expected such discussions to have been initiated by the government.</p>
<p>"There may of course be a Plan A which Whitehall has worked out in huge detail, and which will come into effect as soon as we have a pandemic, but they are keeping everything close to their chest," says a senior executive in a major company. "What they need to realise is that it's just not possible for a company to prepare for this unless you have an idea of how the transport system would run, or whether the schools would still be open."</p>
<p>The Ministry of Defence has been equally unforthcoming. The army would play a crucial role in protecting supplies of drugs at surgeries, ensuring food supplies and maintaining public order, but when MoD representatives spoke at a recent bird flu conference, they demanded that the media be kept away. Such an approach is unlikely to instil confidence in a population that can receive hourly updates on the spread of H5N1, but is not able to find out how they, and the authorities, are supposed to respond.</p>
</div></div></div>Mon, 27 Feb 2006 12:00:00 +0000Jo Revill152638 at http://www.newstatesman.comhttp://www.newstatesman.com/node/146454
<div class="field field-name-field-subheadline field-type-text-long field-label-hidden view-mode-fulltext"><div class="field-items"><div class="field-item even"><p>Labour and Tories may argue about the future of the NHS, but the British public is voting with its f</p>
</div></div></div><div class="field field-name-body field-type-text-with-summary field-label-hidden view-mode-fulltext"><div class="field-items"><div class="field-item even" property="content:encoded"> <p>It was always going to be a pensioner who would test the resolve of the government when it came to patients' rights. Yvonne Watts, a 72-year-old from Bedford, has thrown government lawyers and health service managers into a state of apoplexy over her decision to go to France for a hip operation. A high court ruling on her case raised the possibility of thousands of patients, facing long and painful waits for surgery, going abroad for treatment and leaving the NHS to foot the bill.</p>
<p>Watts, who suffers from arthritis, was told last year she would have to wait 12 months for a hip operation at her local hospital. She asked health managers for their approval to go abroad for surgery on the NHS, but was turned down. She seemed in for a long wait and life in a wheelchair. So she went anyway, and had the operation in Normandy this March. Then she mounted a case against Bedford Primary Care Trust and the Secretary of State for Health.</p>
<p>Although she lost the case on a technicality - health service managers had moved her up the waiting list by the time she had the surgery - the victory was hers. The judge, Mr Justice Munby, decided that under EU law, the state could not refuse to authorise treatment abroad if patients faced an "undue delay" at home.</p>
<p>But what constitutes an "undue" delay? For Yvonne Watts, the tolerable period of delay was deemed less than a year, though "significantly, but probably not substantially" more than the two or three months she would have waited once the operation was brought forward. </p>
<p>With 66,000 people in Britain currently staying more than six months on the list for orthopaedic operations, the ruling throws open the prospects of hundreds, if not thousands, of courtroom challenges. Waiting lists are no longer a barrier to a person's right to healthcare, the ruling makes clear. For 55 years, the NHS has worked on the basis of everyone waiting their turn; now, it looks as if the queue will become an undignified scramble for a lawyer.</p>
<p>Before patients head for the Eurostar terminal, however, they should note the conditions that the judge laid down. No one is entitled to treatment abroad without prior approval, in the form of written support from a GP and a consultant. A primary care trust would then have to grant prior authorisation. The trusts have braced themselves for a flood of inquiries from patients, which must then be sent to lawyers and strategic health authorities, who in turn are waiting for guidance from the Department of Health.</p>
<p>Other cases are in the pipeline, such as that of 67-year-old Robert Towner, who lives near Tunbridge Wells in Kent. He has been told he might wait a year for a hip operation on the NHS. But as his hip crumbles away, affecting the nerves and the joint, every day is painful. His wife, Maggie, told the BBC: "We talked about the possibility of having the operation done privately . . . but it would take every last penny of our savings." She also said: "He cannot wait for 12 months. He can't sleep and he can't walk very far."</p>
<p>The Department of Health, meanwhile, is considering the high court ruling and its implications for the waiting-list policy. Speaking after the judgement, John Reid, the Health Secretary, made the point that the NHS cannot reduce the queues over-night, and called for "realism".</p>
<p>Realism is all very well, but this appears to be a call for patience, which flies in the face of the government's promises to give patients more choice. And choice is the Holy Grail that underpins all of Labour's reforms - foundation hospitals, privately run treatment centres, computerised booking systems, walk-in GP surgeries. But when Tony Blair spoke of giving patients the right to choose which hospital they went to, he did not have Lille or Milan in mind. He was thinking more of a choice between Coventry and Birmingham. Patients, however, like the idea of a consumer-friendly health service, and appear to define the term much more broadly. (The Tories have cleverly capitalised on this with their "passport" system for health, partly reimbursing patients for the cost of going private.)</p>
<p>The Yvonne Watts ruling puts Labour under pressure as never before. Some legal experts are saying that, for urgent cases, anything beyond a month on a waiting list constitutes undue delay.</p>
<p>And Labour has good reason to worry about waiting lists. The number of patients in the queue has fallen to below one million, which is good, but latest official statistics show that those on the list wait longer than they did in 2000. Those waiting more than nine months rose from 49,000 to 52,000 by the end of August.</p>
<p>Added to this woe is the time they spend waiting to get on the waiting list. When she first became ill, Yvonne Watts was told she would have to wait 21 weeks to see an orthopaedic consultant. She booked a private appointment with him.</p>
<p>The loyalty of patients, particularly the elderly, is ebbing away, though all will express a high regard for staff. Twenty years ago, no 67-year-old would discuss going to Lille for a hip operation. Last year, more than 1,120 NHS patients were treated under the government's scheme to beat the queues. Many thousands more went of their own accord, and paid out of their own pocket.</p>
<p>As the research shows (above), even South Africa is considered a possible destination. Last year, more than 100 travelled there for heart surgery. People are more familiar with travelling and are better informed of other healthcare systems. Automatic loyalty is disappearing. People do not like being treated as statistics, and see the NHS as slow and unresponsive. It was certainly unresponsive to Yvonne Watts. The question now for ministers is: what happens to the NHS when patients no longer feel a duty to wait quietly, with British stoicism, in the long queue for care?</p>
<p><em>Jo Revill is health editor of the </em>Observer</p>
</div></div></div>Mon, 13 Oct 2003 12:00:00 +0000Jo Revill146454 at http://www.newstatesman.comhttp://www.newstatesman.com/node/141812
<div class="field field-name-field-subheadline field-type-text-long field-label-hidden view-mode-fulltext"><div class="field-items"><div class="field-item even"><p>Before the Chancellor raises taxes to pay for the NHS, he should ask what happened to the last injec</p>
</div></div></div><div class="field field-name-body field-type-text-with-summary field-label-hidden view-mode-fulltext"><div class="field-items"><div class="field-item even" property="content:encoded"> <p>The safe lies empty; its door swings open as a team of detectives hunts for clues left behind by the thief. A scrap of the NHS plan, a tell-tale ministerial fingerprint and a stained scalpel are all that remain in the quest for the missing billions. The butler, one A Milburn, has come under heavy suspicion. And did the man at No 11 keep an eye on the premises carefully enough? Was it an inside job?</p>
<p>Before we throw our hats in the air at the latest promises of more money for the health service, perhaps someone should solve this mystery. In 1998, when the Chancellor announced £21bn for the NHS over three years, the reaction was one of glee, tinged with disbelief. Once triple-accounting was discounted, the real figure came closer to £12bn, but nobody denied it was a sizeable increase, pushing health spending to a year-on-year rise of roughly 6.1 per cent in real terms. Hospitals and GPs' surgeries, we thought, would be awash with cash as the monolithic service was transformed into a modern, clean, computerised, even patient-friendly organisation.</p>
<p>More cash followed. By next year, the total NHS budget will have risen by more than one-third in just five years, to £65bn. Where did it all go? How could such a colossal sum vanish with so little effect? The disappearing act perplexes everyone, and nobody more than the Chancellor.</p>
<p>When the money first came through in 1999, it felt like Christmas. For the first time, hospital chief executives found themselves with as much money as they wanted in order to try to clear their waiting lists. If they decided to send 200 patients to the local Bupa hospital for hip operations, to avoid the 12-month waiting time, that was fine. If they wanted to open up a ward that had been mothballed for the past few years, they got the thumbs-up.</p>
<p>But as the Health Secretary, Alan Milburn, quickly realised, you can't spend money if you do not have the staff to hire. An intensive care bed requires three nurses over a 24-hour period. If you can find only two, the bed has to close, and the heart operation due that morning for the patient in it has to be cancelled. Repeat that on several days, and you soon have an embryonic waiting list problem.</p>
<p>So hospitals were left with two courses of action. One was to recruit staff from abroad. Nobody has ever calculated the cost of this, but given, for example, that one in three nurses working in London now comes from overseas, it will be substantial. The other solution was to pay nursing agencies to provide temporary staff.</p>
<p>It became a vicious circle. As the shortages began to bite, more staff joined the agencies. Why stay on the staff of your local hospital trust, earning £18,000 running a ward, when you can go freelance, choose your own hours, not have any managerial responsibility, and earn nearly twice as much? Agency nurses and sick pay account for approximately £2bn a year now, double the extra cash the Chancellor announced for next year's NHS budget in his autumn statement.</p>
<p>Most of the missing billions went on simply trying to keep staff, so that the one benefit of having a monopoly employer - the ability to exert strong cost controls - went out the window. Salaries rose above inflation - up by 9 per cent last year for London's nurses. The health trusts spent sizeable sums wooing staff with bonuses, childcare facilities and more flexible working hours. And yet a nurse responsible for a busy coronary unit in 2001 will still not earn as much as the manager of the local cappuccino bar.</p>
<p>Not all the money was soaked up immediately. Consultants' requests for new diagnostic laboratories are being met, provided they speed up treatment for heart disease or cancer, the government's two biggest priorities. Nor have the funds dried up for reducing waiting lists. Milburn has just announced that patients will have the right to a bed in the private sector if they face a six-month wait for an operation.</p>
<p>But if the NHS has this kind of money, why do we not feel better off? By now, surely, people should have some confidence that they will be seen in less than four hours at an accident and emergency unit, or feel that they could make an appointment with their GP within the week. Yet the waiting times in casualty departments have lengthened, and the overall numbers being treated have barely shifted in the past year.</p>
<p>All the evidence suggests that the billions were simply absorbed into a system that was bone dry. Labour's biggest political error was that it failed, at an early stage, to spell out the size of the funding gap between the UK and other industrialised nations. When Gordon Brown made his announcement in 1998, Britain was not just lagging behind other countries on the health front - it wasn't even in the race. The expenditure per head of population was lower in the UK than in any comparable country, apart from New Zealand. At £1,510 per person, it was 13 per cent lower than in Sweden, and roughly 30 per cent lower than in Australia, France or the Netherlands.</p>
<p>It had been low for a very long time. Derek Wanless, whose report gave the Chancellor the ammunition for the health offensive in his autumn Budget preview, believes that, between 1972 and 1998, the UK suffered a cumulative underspend of between £220bn and £260bn.</p>
<p>When the money came, it was swallowed up not only in staff costs, but in a plethora of initiatives. One London health authority got an extra £100m for the current year. A study by the King's Fund, the health think-tank, found that after the authority had paid for all the "must-dos" laid down by the NHS regional office - reducing waiting times, meeting the EU working time directive for doctors, and providing services to cut smoking and teenage pregnancy, for example - it was left with discretion over how to spend just 20 per cent of the money. For a London authority, £20m is peanuts; it won't even build you a new day surgery centre.</p>
<p>Bureaucracy, the cost of which nobody can fully calculate, must also take some of the blame. The head of one hospital described to me how ordering new mattresses for beds last winter took five days, because the form had to be signed by three different officials. If a commercial firm ran its order books this way, it wouldn't survive the winter.</p>
<p>There is another, fairly obvious reason for our discontent with the health service. If you treat patients in shoddy buildings, it won't feel like much of an improvement. Banks and post offices have changed, but the hospitals endure as Lithuanian-style, 1960s concrete blocks, strewn with litter and a bewildering array of signposts.</p>
<p>Sixty-eight new hospitals, under the private finance initiative, have been agreed, but their creation is a lengthy, cumbersome process. The Royal London Hospital in the East End of London, one of the biggest and most complex developments, has a completion date of 2010. Can Labour afford to wait another nine years for hospitals such as this to be built, if record sums are simultaneously going into drugs, equipment and staff?</p>
<p>Tony Blair has so far avoided the question of where the previous handouts have gone, but he is adamant that the money has made a difference. Very soon, he says, major cancers will "get from diagnosis to treatment within a month". But talk to Germans about the happy prospect of waiting a month for their chemotherapy to begin, and they would think you were mad.</p>
<p>It is the difference between Britain and Europe, not the difference between Britain 2001 and Britain 1991, that people care about. One cancer specialist told me recently about his team's jubilation at achieving one of their targets: to ensure that all children with suspected cases of leukaemia see a specialist within three days. Then they found out that, in Paris, the <em>treatment</em> begins within three days.</p>
<p>France's healthcare is good, and expensive, because it has spare beds, spare units and spare staff to cope with changes in demand. Britain has not been in that position for three decades. At present levels of spending, it would probably need an increase of between one-quarter and one-third in its capacity to reach that point.</p>
<p>If Labour is to convince the public of the need for higher taxes, it must explain how that £21bn vanished. Was it absorbed too quickly into the arid soil of the NHS, keeping alive a system close to collapse? Or was much of it squandered on failed initiatives such as the waiting list pledge?</p>
<p>Gordon Brown cannot just thump the table and say that the new money will be coupled with rigorous reform; that is exactly what was supposed to have happened during the past three years. He needs to cast a colder, more forensic eye over where the missing billions went.</p>
<p><em>Jo Revill is a political reporter, and the former health correspondent, for the London </em>Evening Standard</p>
</div></div></div>Mon, 10 Dec 2001 12:00:00 +0000Jo Revill141812 at http://www.newstatesman.com